Download Assessment

Nursing Process Focus
Patients Receiving Morphine
Potential Nursing Diagnoses
Assessment
Prior to administration:
 Obtain complete medical history including  Knowledge deficient, related to drug action
allergies, pulmonary, cardiac, renal, biliary,
and side effects
and mental or sleep disorders, including
 Pain, Acute
EKG and laboratory studies: CBC, BUN,
 Breathing pattern, Ineffective, related to
creatinine, electrolytes, liver function tests
sedation effect of drug
(AST, Amylase, bilirubin).
 Constipation, related to drug action
 Obtain patient’s drug history to determine
 Sleep Pattern disturbed (increased sleep),
possible drug interactions and allergies
related to drug effect
 Assess respiratory function.
 Assess LOC and pain.
Planning: Patient Goals and Expected Outcomes
The patient will:
 Report pain relief or a reduction in pain intensity.
 Demonstrate understanding of the drug's action by accurately describing drug side effects
and precautions.
 Immediately report effects such as untoward or rebound pain, restlessness, anxiety,
depression, hallucination, nausea, dizziness, and itching
 Maintain respiratory rate at least twelve beats per minute
 Maintain bowel function within normal pattern
Implementation


Interventions and (Rationales)
Monitor vital signs. Cardiac output and
central venous pressure may be needed.
Assist with monitoring according to
cardiac care unit (CCU) or emergency
department (ED) protocols.
Monitor liver enzymes and observe the
patient for abdominal distention,
tenderness and rigidity. (Morphine may
intensify or mask the pain of gallbladder
disease. Morphine can cause anorexia,
nausea and vomiting, and may trigger
biliary tract spasms. Morphine also raises
serum amylase levels.)
Patient Education/Discharge Planning
Instruct the patient:
 That feeling dizzy or light-headed can be
the result of analgesia, or coronary
ischemia
 To report episodes of severe dizziness or
impending syncope immediately.
Instruct the patient to:
 Report any history or symptoms of biliary
tract or liver disease, such as
cholecystectomy.
 Report signs and symptoms of hepatic
toxicity: nausea, vomiting, diarrhea, rash,
jaundice, abdominal pain, tenderness or
distention, or change in color of stool
 Adhere to the schedule of laboratory
testing for liver function as ordered by the
health care provider.

Instruct patient or caregiver to:
 Monitor vital signs regularly, particularly
respirations.
 Withhold medication for any difficulty in
breathing or respirations below 12 breaths
per minute.
 Keep resuscitative equipment and
 Inform patient and caregivers concerning
narcotic-agonist (naloxone) medication at
need for resuscitative equipment and
hand. Withhold the drug if the patient's
rationale for frequent monitoring of
respiratory rate below 12.
respiratory rate.
Instruct
the patient to:
Monitor neurological status

Report
headache or any significant change
 Perform neuro-checks regularly. Monitor
in
sensorium,
such as an aura or other
changes in level of consciousness (LOC).
visual affects that may indicate an
(Decreased LOC and sluggish pupillary
impending seizure.
response may occur with high doses.
 The possibility of seizures and methods to
May cause increased CO2 content of
ensure personal safety during a seizure.

Report any seizure activity immediately to
blood, dilating cerebral vessels causing
the nurse or health care provider.
ICP.). Observe for seizures.
Instruct the patient:
 Interview patient regarding the location,
quality, intensity, and frequency or
 Alert the nurse immediately upon the
duration of pain; use a nominal scale to
return or increase of pain.
determine intensity. (Administer
 Notify the health care provider regarding
medication before pain becomes intense
the drug's effectiveness.
to help keep pain under control.)
Instruct patient or caregiver to:
 Monitor renal status and urinary output.
 Measure and monitor fluid intake and
(May cause urinary retention due to
output.
muscle relaxation in urinary tract.
 Notify the health care provider for any
Opiates are excreted through the kidneys.
symptoms of dysuria (hesitancy, pain,
Impaired kidney function may result in
diminished stream), changes in urine
reduced medication clearance and
quality or scanty urine output.

Notify the health care provider of fever or
increased serum drug levels. Urinary
flank pain that may be indicative of a
retention may exacerbate existing
urinary tract infection related to urinary
symptoms of prostatic hypertrophy.)
retention.
Instruct patient or caregiver to:
 Monitor for side effects such as
 Report any side effects and symptoms of
restlessness, dizziness, anxiety,
an allergic or anaphylactic reaction.
depression, hallucinations. (Opiates bind
 Immediately report any shortness of
mu and kappa receptors in the brain and
breath, tight feeling in the throat, itching,
spinal cord. Stimulation of
hives or other rash, feelings of dysphoria,
chemoreceptors in the GI tract may
nausea or vomiting.
 Avoid the use of sleep-inducing over-theproduce nausea and vomiting.)
counter antihistamines, without first
 Monitor for hives or itching. (These
consulting the health care provider.
symptoms may indicate an allergic
reaction due to the production of
histamine.)
Monitor vital signs, especially depth and
rate of respirations andpulse oximetry.
(Opioids interact with receptors in the
brain; respiratory depression and cardiac
arrest may occur.)

Instruct patient:
 Maintain an adequate fluid and fiber
intake to facilitate stool passage.
 A stool softener and/ laxative may be
necessary; consult health care provider.
Instruct patient to:

 Request assistance when getting out of
bed
 Avoid activities that require mental
alertness and physical coordination until
effect of drug is known
Inform
patient:
 Monitor for tolerance/dependence.

That
with continued therapy, dosing or
(Continued long-term use of opioids
drug
administration routes may need to be
results in tolerance to the drug's desired
changed to produce the same level of pain
effect and physical dependence on the
relief.
drug itself. Increased dosing or
 Regarding cross-tolerance issues.
administration route changes may be
 Concerning the issue of drug-dependence
from the perspective of reduced liferequired to maintain analgesia. Crossexpectancy.
tolerance may also develop to other

To inform caregivers to monitor
narcotics such as methadone, meperidine
medication supply to observe for
and heroin.)
hoarding, which may signal an impending
suicide attempt.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).
Monitor for constipation. (Opioids have
an antispasmodic effect on the GI tract,
which decreases peristaltic activity. May
need to increase dietary fiber or
administer laxatives.)
Ensure patient safety. Raise bed rails and
place call bell within patient's reach and
monitor ambulation.
Nursing Process Focus
Patients Receiving Naloxone
Potential Nursing Diagnoses
Assessment
Prior to administration:
 Obtain complete medical history:
 Breathing pattern, Ineffective, related to
pulmonary, cardiac, renal, biliary, and
drug effect
mental disorders, including EKG and chest
 Airway clearance, Ineffective, related
x-ray, pulse oximetry, laboratory studies:
to sedation effect of drug
CBC, BUN, creatinine, electrolytes,
 Ventilation, Impaired spontaneous
arterial blood gases, etc.
related to respiratory depression
 Obtain patient’s social and drug history to
 Aspiration, Risk for related to
determine drug usage patterns, possible
decreased airway clearance
hypersensitivity, possible pregnancy and
 Tissue perfusion, Ineffective related to
lactation.
decreased ventilation
 Assess for respiratory dysfunction/
depression (character, rhythm, and rate of
less and 10 breaths/minute).
 Assess for LOC and pain before and after
administration.
Planning: Patient Goals and Expected Outcomes
The patient will:
 Maintain a respiratory rate of 12 breaths per minute or more.
 Demonstrate understanding of the drug's action by accurately describing the drug's sideeffects and precautions.
 Demonstrate ability to effectively clear airway
 Avoid aspirating gastric content or oral fluids
 Demonstrate adequate tissue perfusion
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
 Monitor vital signs, including respirations,  Inform patient or caregiver that the drug's
cardiac output, central venous pressure,
purpose is to restore respiratory capacity.
etc. (per ICU/ED protocol).
Inform patient or caregiver that:
 Monitor tissue perfusion.
 Despite naloxone therapy, mechanical
 Obtain ABGs including PO2 and PCO2
ventilation may still be necessary.
before and after administration. (Low PO2
may indicate the need for mechanical
 Arterial blood gases are used as guidelines
ventilation.)
for determining the patient's need for
respiratory support.
 Monitor neurological status and level of
 Instruct patient to inform the nurse
pain.
regarding a return or worsening of pain,
any changes in sensorium or feelings of
 Monitor mental status and observe for
dysphoria.
changes in LOC and adverse effects such
as persistent drowsiness, hallucinations or
suicidal ideation.
 Perform neurochecks according to
unit/department protocols.


Monitor for signs of acute drug withdrawal
such as extreme anxiety, ventricular
tachycardia, hypertension nausea and
vomiting, or muscle cramping.
(Withdrawal symptoms are precipitated by
rebound stimulation of the CNS.)
Instruct the patient or caregiver that:
 Naloxone is indicated for emergency use,
and is not intended as a low-risk or
ordinary back-up for opiate binges.
 Withdrawal produced by opiate antagonists
is more severe, and therefore can be more
agonizing and dangerous than spontaneous
withdrawal.
Instruct the patient to:
 Immediately report any shortness of breath
or a productive cough with frothy sputum
(signs of pulmonary edema).
 Immediately report any angina-like
symptoms: chest, arm or back pain or
pressure, dizziness, nausea, diaphoresis,
etc.
Use with caution in patients with cardiac
disease. (The effect of naloxone on the
central nervous system results in the
massive release of catecholemines, which
causes blood volume to shift into the
pulmonary vasculature. This vascular
congestion may result in pulmonary
edema. This shift also increases cardiac
workload.)
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).
Nursing Process Focus:
Patients Receiving Aspirin
Potential Nursing Diagnoses
Assessment
Prior to administration:
 Obtain complete medical history including
 Pain (acute and chronic), related to tissue
allergies, cardiac, renal, gastro-intestinal,
damage or inflammatory process
biliary, and hematologic, including chest x-  Knowledge Deficient, related to drug
ray, laboratory studies: CBC, PT, PTT,
action and side effects
BUN, creatinine, electrolytes, liver
 Altered Health Maintenance, related to
enzymes , etc.
unrelieved pain
 Obtain patient’s drug history to determine
pain and analgesic usage patterns, possible
hypersensitivity, possible pregnancy and
lactation.
 Identify infectious agents or other factors
responsible for inflammation or pain;
Planning: Patient Goals and Expected Outcomes
The patient will:
 Report pain relief or a reduction in pain intensity.
 Demonstrate understanding of the drug's action by accurately describing drug side effects
and precautions.
 Immediately report effects such as unresolved, untoward or rebound pain, persistent fever,
blurred vision, tinnitus, bleeding, changes in color of stool or urine.
Implementation


Interventions and (Rationales)
Exercise extreme caution in
administering ASA to children and
teenagers. (ASA has been implicated in
the development of Reye's syndrome in
conjunction with "flu-like" illnesses.
Febrile, dehydrated children can rapidly
develop ASA toxicity.)
Monitor vital signs, especially
temperature. (Increased pulse and BP
may indicate discomfort; accompanied
by pallor and/or dizziness may indicate
bleeding.)
Patient Education/Discharge Planning
Instruct the patient or caregiver to:
 Always first choose a non-aspirin
preparation to treat fever.
 Consult the health care provider
immediately if the non-aspirin antipyretic
is ineffective.
 Be aware of hidden sources of ASA in
over-the-counter medications such as
menstrual pain relief compounds and
"pink bismuth liquid" for gastrointestinal
distress.
Instruct the patient:
 Report rapid heartbeat, palpitations,
dizziness or pallor.
 Monitor blood pressure and temperature
ensuring proper use of home equipment.

Monitor for signs of gastrointestinal
bleeding or hepatic toxicity, specifically
guiac stool testing for occult blood and
CBC for signs of anemia. (ASA is a local
irritant to the GI tract with anticoagulant
action that is metabolized in the liver.)

Obtain character, duration, location, and
intensity of pain and the presence of
inflammation.
Monitor for allergic responses. Report to
health care provider.





Monitor urinary output and edema in
feet/ankles. (Medication is excreted
through the kidneys. Long term use may
lead to renal dysfunction.)
Monitor CBC, BUN, creatinine, and
urinalysis.
Monitor for sensory changes indicative
of drug toxicity: tinnitus, blurred vision.
Instruct the patient to:
 Report any frank bleeding, abdominal
pain, anorexia, heartburn, nausea,
vomiting, jaundice or a change in the color
or character of stools.
 Adhere to a regimen of laboratory testing
as ordered by the health care provider.
 Keep all follow-up appoints as directed by
the health-care provider.
Inform patient that
 Vomiting brown emesis that looks like
coffee grounds or passing tarry stools are
signs of gastrointestinal bleeding.
 The method of obtaining stool samples
and home testing for occult blood as
indicated by the health care provider.
 Instruct patient notify nursing personnel if
pain and/or inflammation remains
unresolved.
 Advise the patient to immediately report
shortness of breath, wheezing, tightness in
the throat, itching or hives. Advise the
patient to stop taking ASA immediately
and inform the health care provider.
 Instruct patient to report changes in
urination, flank pain or pitting edema
immediately.

Advise the patient to immediately report
any sensory changes in sight or hearing,
especially blurry vision or "ringing in the
ears."
Ensure that patient knows to adhere to the
schedule of laboratory testing for liver
function as ordered by the health care
provider.
Evaluate blood salicylate levels,

especially in the elderly. (Elderly patients
are particularly at risk due to diminished
kidney and liver function related to
aging.)
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).
Nursing Process Focus:
Patients Receiving Sumatriptan
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Obtain complete medical history including
 Pain, Acute
allergies, cardiac, renal, gastro-intestinal,
 Knowledge Deficient, related to drug
biliary, and hematologic, including EKG,
action and side effects
X-ray, tomography and laboratory studies:
 Coping, Ineffective related to unrelieved
CBC, cardiac enzymes, BUN, creatinine,
pain
electrolytes, liver enzymes , etc.
 Health Maintenance, Ineffective, related
 Obtain patient’s drug history to determine
to unrelieved pain
pain and analgesic usage patterns, possible
hypersensitivity, possible pregnancy and
lactation.
 Identify infectious agents or other factors
responsible for inflammation or pain
 Assess for LOC and pain before and after
administration.
Planning: Patient Goals and Expected Outcomes
The patient will:
 Report pain relief or a reduction in pain intensity.
 Demonstrate understanding of the drug's action by accurately describing drug side effects
and precautions.
 Immediately report effects such as shortness of breath, chest tightness or pressure, jaw
pain, untoward or worsened rebound headache, seizures or other neurological changes.
 Demonstrate ability to manage health needs
Implementation




Interventions and (Rationales)
Monitor vital signs, especially blood
pressure and pulse. (Sumatriptin's systemic
vasoconstrictor activity results in a rise in
blood pressure and may result in
arrythmias or myocardial infarction.)
Keep resuscitative equipment accessible.
Observe for changes in severity, character
or duration of headache. (Sudden severe
headaches of "Thunderclap" quality can
signal subarachnoid hemorrhage.
Headaches which differ in quality and are
accompanied by signs such as fever, rash,
stiff neck, etc. may herald meningitis.)
Monitor changes in neurological status;
perform neuro-checks, esp LOC, regularly
(Sumatriptan selectively reduces carotid
arterial blood flow.)
Patient Education/Discharge Planning
 Instruct patients to monitor vital signs,
especially blood pressure and pulse,
ensuring proper use of home equipment.
Instruct the patient:
 That changes in the character of
migraines could signal other potentially
more serious disorders.
 Concerning warning signs of stroke;
 Regarding conditions such as meningitis
which may cause headache.
Instruct the patient to:
 Report episodes of severe dizziness or
impending syncope immediately. Feeling
dizzy or light-headed can be the result of

the drug's action on the CNS, OR
coronary ischemia.
 Review emergency response and safety
measures in the event of a seizure.
Advise
patient to:
 Monitor for possible side effects: dizziness
drowiness, warming sensation, tingling,
 Immediately report side effects to the
lightheadness, weakness or neck stiffness
health care provider. Regarding emergent
due to vasoconstriction. (Such symptoms
symptoms suggestive of stroke or
can result from decreased blood flow to
myocardial infarction, which may require
the brain related to reduced carotid arterial
immediate emergency intervention and
blood supply.)
transport to a hospital.
Instruct the patient to:
 Monitor dietary intake of foods that
contain tyramine such as pickled foods,
 Avoid or limit foods containing tyramine.
beer, wine, aged cheese which may trigger
migraines.
Instruct the patient to:
 Monitor laboratory tests such as CBC,
BUN, creatinine, urinalysis and liver
 Report nausea, vomiting, diarrhea, rash,
enzymes to determine kidney and liver
jaundice, abdominal pain, tenderness,
function. (Sumatriptan is metabolized in
distention, or change in color of stool.
the liver and excreted by the kidneys;
 Adhere to laboratory testing regimen for
impaired organ function can increase
serum blood level tests of liver enzymes as
serum drug levels.) Report immediately.
directed.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).
Observe for seizures.